- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,581.13 / $2,581.13 / $2,581.13
| Facility | | $2,581.13 | $2,581.13 | $2,581.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.30 / $1,853.22 / $2,581.13
| Professional | | $1,473.30 | $1,853.22 | $2,581.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $159.19 / $367.40 / $2,149.26
| Facility | | $159.19 | $367.40 | $2,149.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $159.19 / $171.45 / $2,314.59
| Professional | | $159.19 | $171.45 | $2,314.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,997.20 / $1,997.20 / $3,360.51
| Facility | | $1,997.20 | $1,997.20 | $3,360.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $1,472.88 / $8,352.10
| Professional | | $192.51 | $1,472.88 | $8,352.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.92 / $646.37 / $3,504.84
| Professional | | $273.92 | $646.37 | $3,504.84 |